Many of the same techniques used to address acute fractures have been described for nonunions. Both some form of internal fixation with or without bone graft,20–23 conventional arthroplasty,24 or reverse geometry arthroplasty have been described.25 Scheck21 used corticocancellous iliac crest cancellous graft in combination with Rush pins. Nayak et al17 reported on a treatment with either open reduction, internal fixation with tension band wiring and Rush rods or hemiarthroplasty. Ring et al20 and Sonnabend22 have published their results on the use of blade plates. Walch et al26 first proposed the use of an intamedullary bone peg to treat proximal humeral nonunions. Corticocancellous graft was harvested from the iliac crest, anterior tibia, or fibula to supplement fixation with either a T-plate or a blade plate. Peripheral cancellous bone graft was also packed around the fracture site. Galatz et al18 has reported on the use of autogenous cancellous bone graft and either a blade plate or a T-plate. The use of a locked plate with intramedullary fibular strut allograft27 and autogenous iliac crest cancellous graft28 has more recently been described. We describe the use of a locked proximal humeral plate in combination with an autogenous iliac crest corticocancellous bone peg. In general, the results of surgery for proximal humeral nonunions are not as satisfactory as those for fixation of acute fractures.29
The procedure is usually performed under general anesthesia with an interscalene block. The patient is placed in a semi-beachchair position paying attention to be able to perform intraoperative fluoroscopy during the procedure. The arm is free draped and the iliac crest is prepped and draped. A deltopectoral approach is performed. The subdeltoid and subacromial spaces are released of adhesions. The rotator interval is opened and the long head of biceps tenotomized at the superior pole of the glenoid in preparation for later soft tissue tenodesis to the tendon of pectoralis major. The fracture site is identified and fibrous tissue and callus is carefully taken down. A curette is used to remove soft tissue from within the humeral head defect and freshen the margins of the cavity. The tuberosities are mobilized if required and tagged with stay sutures. The humeral head fragment is mobilized gently and reduced. This is either done with pressure from below with an elevator or by using a K-wire as a joystick. If the tuberosities are intact, the stay sutures can be used to assist with reduction. Care is taken to avoid causing any unnecessary further disruption of the medial calcar region. This region can usually be visualized from within the fracture due to extensive missing bone within the humeral head. Intraoperative fluoroscopy is used to confirm satisfactory reduction. A final assessment is made regarding the likely viability of the head fragment and the ability to obtain secure fixation. If the decision is made to continue with fixation, then bone graft is harvested at this stage. An oblique incision is made 2 cm below and parallel to the anterior iliac crest paying attention to avoid the lateral cutaneous nerve of the thigh. The crest is exposed subperiosteally on its superior surface and over its outer table for 2 cm and to define the location of the inner table. The graft can be harvested either with osteotomes or an oscillating saw. The graft is generally 6 cm long and consists of 2 cm of lateral cortex and the entire thickness of the inner cancellous bone. This leaves only the cortex of the inner table in situ. This yields a corticocancellous bone peg of approximately 6×2×1 cm. Occasionally, in patients with very thin iliac crests, we have harvested a tricortical graft of similar dimensions but including the inner table. Further cancellous bone is harvested from the iliac crest through the bony defect. Particular care is taken to close the periosteum over the donor site and the deep fascia to prevent hematoma formation.
The graft is now shaped with a rongeur according to the intramedullary diameter of the proximal humerus and the bony defect in the humeral head. The prepared graft is inserted into the medullary canal of the humeral shaft, and the humeral head is trial reduced on to the graft. Repeated modifications of the graft are often necessary until the graft fits within the humeral head defect enabling satisfactory reduction. Rotation is assessed clinically using the biceps groove as a guide. If the temporary reduction is not stable, then it may be held with provisional K-wires at this stage. The construct is now stabilized with a PHILOS locking proximal humerus plate placed lateral to the bicipital groove.
The plate is fixed to the shaft either with a K-wire or with a nonlocked shaft screw through the slotted sliding hole. The height of the plate is now checked clinically and radiologically to avoid subacromial impingement and also to ensure that a locked inferomedial calcar screw can be placed. The locking screws into the head fragment are now placed followed by nonlocking cortical screws into the remaining shaft holes.
Postoperatively, the patient is kept in the sling for 6 weeks allowing removal for pendular exercises and axillary hygiene purposes only. Elbow wrist and hand movements are encouraged. Radiographs are taken at 2 and 6 weeks postoperatively, and if appearances are satisfactory, passive-assisted and active-assisted range of motion exercises are introduced. Active strengthening exercises are introduced at 12 weeks.
There are only a small number of reported series of treatment of proximal humeral fracture nonunions. Most of these studies report results using conventional implants. For the most part, these implants have been superseded by newer designs such as anatomic-specific precontoured locking plates, which provide superior angular stability. Although the use of locked plates is widespread for proximal humeral fractures, their mixed results has led to the development of techniques to restore or augment the calcar region to prevent varus collapse. The technique described above incorporates the use of a locked plate in addition to an iliac crest corticocancellous bone peg to augment the mechanical strength of the calcar region and autogenous cancellous bone graft in an attempt to enhance union rates. We have found this technique to be successful in the treatment of nonunions resulting from both nonoperative and operative treatment of proximal humeral fractures (Fig. 5).
1. Horak J, Nilsson BE.Epidemiology of fracture
of the upper end of the humerus.Clin Orthop Relat Res. 1975;112:250–253.
2. Helmy N, Hintermann B.New trends in the treatment of proximal humerus
fractures.Clin Orthop Relat Res. 2006;442:100–108.
3. Badman BL, Mighell M.Fixed-angle locked plating of two-, three-, and four-part proximal humerus
fractures.J Am Acad Orthop Surg. 2008;16:294–302.
4. Wanner GA, Wanner-Schmid E, Romero J, et al..Internal fixation of displaced proximal humeral fractures with two one-third tubular plates.J Trauma. 2003;54:536–544.
5. Sperling JW, Cuomo F, Hill JD, et al..The difficult proximal humerus fracture
: tips and techniques to avoid complications and improve results.Instr Course Lect. 2007;56:45–57.
6. Wagner M.General principles for the clinical use of the LCP.Injury. 2003;34(suppl 2):B31–B42.
7. Fankhauser F, Boldin C, Schippinger G, et al..A new locking plate
for unstable fractures of the proximal humerus
.Clin Orthop Relat Res. 2005;430:176–181.
8. Koukakis A, Apostolou CD, Taneja T, et al..Fixation of proximal humerus
fractures using the PHILOS plate: early experience.Clin Orthop Relat Res. 2006;442:115–120.
9. Owsley KC, Gorczyca JT.Fracture
displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected].J Bone Joint Surg Am. 2008;90:233–240.
10. Gardner MJ, Weil Y, Barker JU, et al..The importance of medial support in locked plating of proximal humerus
fractures.J Orthop Trauma. 2007;21:185–191.
11. Hepp P.Biology and biomechancs in osteosynthesis of proximal humeral fractures.Eur J Trauma Emerg Surg. 2007;33:337–344.
12. Osterhoff G, Baumgartner D, Favre P, et al..Medial support by fibula bone graft
in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone.J Shoulder Elbow Surg. 2011;20:740–746.
13. Galatz LM, Iannotti JP.Management of surgical neck nonunions.Orthop Clin North Am. 2000;31:51–61.
14. Neer CI.Nonunion
of the surgical neck of the humerus.Orthop Trans. 1983;7:389.
15. Healy WL, Jupiter JB, Kristiansen TK, et al..Nonunion
of the proximal humerus
. A review of 25 cases.J Orthop Trauma. 1990;4:424–431.
16. Egol KA, Ong CC, Walsh M, et al..Early complications in proximal humerus
fractures (OTA types 11) treated with locked plates.J Orthop Trauma. 2008;22:159–164.
17. Nayak NK, Schickendantz MS, Regan WD, et al..Operative treatment of nonunion
of surgical neck fractures of the humerus.Clin Orthop Relat Res. 1995;313:200–205.
18. Galatz LM, Williams GR Jr, Fenlin JM Jr, et al..Outcome of open reduction and internal fixation of surgical neck nonunions of the humerus.J Orthop Trauma. 2004;18:63–67.
19. Jarvinen M, Kannus P.Injury of an extremity as a risk factor for the development of osteoporosis.J Bone Joint Surg Am. 1997;79:263–276.
20. Ring D, McKee MD, Perey BH, et al..The use of a blade plate and autogenous cancellous bone graft
in the treatment of ununited fractures of the proximal humerus
.J Shoulder Elbow Surg. 2001;10:501–507.
21. Scheck M.Surgical treatment of nonunions of the surgical neck of the humerus.Clin Orthop Relat Res. 1982;167:255–259.
22. Sonnabend DH.Blade plate fixation of humeral neck fractures and nonunions in osteoporotic bone.J Shoulder Elbow Surg. 1993;2 suppl 49.
23. Volgas DA, Stannard JP, Alonso JE.Nonunions of the humerus.Clin Orthop Relat Res. 2004;419:46–50.
24. Antuna SA, Sperling JW, Sanchez-Sotelo J, et al..Shoulder arthroplasty for proximal humeral nonunions.J Shoulder Elbow Surg. 2002;11:114–121.
25. Martinez AA, Bejarano C, Carbonel I, et al..The treatment of proximal humerus
nonunions in older patients with the reverse shoulder arthroplasty.Injury. 2012 [Epub ahead of print].
26. Walch G, Badet R, Nove-Josserand L, et al..Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting.J Shoulder Elbow Surg. 1996;5:161–168.
27. Badman BL, Mighell M, Kalandiak SP, et al..Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft.J Orthop Trauma. 2009;23:173–179.
28. Dwyer A, Patnaik S, Smibert J.Nonunion
of complex proximal humerus
fractures treated with locking plate
.Injury Extra. 2007;38:409–413.
29. Cheung EV, Sperling JW.Management of proximal humeral nonunions and malunions.Orthop Clin North Am. 2008;39:475–482 vii.